During the pandemic (phase one and two)
During the recent Coronavirus disease 2019 (COVID-19) outbreak in China, 54% of the participants of a large online study rated the impact of the outbreak on their mental health as moderate to severe, with depressive symptoms and anxiety being the conditions most often stated . The current crises imposes multifaceted burdens on children. They include the socio-ecological impact of the pandemic, which is understood to be enormous. The environment of children is affected at different levels– including community and family - as well as the individual child itself .
Community-related risks for mental health
Since the pandemic was announced, at the community level, there has been disruption of, or more limited access to basic services, such as kindergarten, schools, and routine medical care . Several countries have seen a re-organization of hospital services, with provisional care (including re-assigning doctors and nurses not usually involved in critical care). There have been closures, partial closures or reduced services of inpatient and day-care facilities, with outpatient contacts reduced in some places to emergency cases only. Some hospitals have been unable to accept new inpatients due to the risk of infection . Questions have arisen on how to deal with the risk of infected patients in closed units infecting staff and other patients. There have been concerns for the possible future lack of adequate resources for mental health services as most resources are directed towards ICU and somatic care . Importantly, even the activity of child protection services and currently existing programs of support or supervision by youth welfare agencies have been disrupted or interrupted . The lack of access to these basic services can be particularly harmful for vulnerable children and/or families.
Moreover, leisure time activities have been limited. In most countries, children have not been allowed to use regular playgrounds, social group activities are prohibited and sports clubs are closed . Social relations have been strongly limited to closest family members. In several countries, contact to peers has been prohibited or severely limited . This can have a negative impact on children and adolescents given the importance of peer contact for well-being [7, 8]. Many countries have experienced a lock-down of schools . As pointed out by a recent review, school closures may not have a major impact on reducing infections and preventing deaths . Hence, possible negative consequences such as loss of education time, restricted access to peers and loss of daily structure need to be taken into account when estimating the advantages and disadvantages of this particular measure. Moreover, in some communities, stigmatization of infected children and families may occur.
Challenges within the families
At the family level, the pandemic has led to a re-organization of everyday life. All family members have to cope with the stress of quarantine and social distancing. School shutdowns have led to home-schooling and potential postponement of exams. Parents have experienced increased pressure to work from home, to keep jobs and businesses running as well as to take care of schooling children at home at the same time, while caregiver resources including grandparents and the wider family have been restricted. Family connections and support may be disrupted. Fear of losing family members who belong to a risk group can increase. In case of death, the pandemic disrupts the normal bereavement processes of families. Grief and mourning of lost family members, especially in cases where contact with the infected member is restricted or refused, could lead to adjustment problems, post-traumatic stress disorder, depression and even suicide of both, adults and young people .
It also has fallen on the parents’ shoulders to inform and explain to children about the COVID-19 pandemic, and to handle fear and anxiety accompanying these uncertain times. All family members may have own fears related to COVID-19. Taken together, this can result in enormous stress and psychological distress for all family members.
The pandemic has major economic implications and puts financial pressure on many families. It has been shown in previous economic recessions that economic pressure, even if not accompanied by social distancing, can pose a severe threat to mental health. Firstly, economic recessions and connected factors such as unemployment, income decline, and unmanageable debts are significantly associated with a decrease of mental well-being, increased rates of several mental disorders, substance-related disorders, and suicidal behaviors [12, 13]—risks that of course also concern parents . The recent recession therefore has added to the fact that low socioeconomic status is a well-known risk factor for poor mental health in children . Mental illness and substance abuse of parents significantly influence parent–child relations [16,17,18] and increase the risk for mental health problems in children .
Domestic violence and child maltreatment
Additionally, in economic recessions a significant increase in domestic violence can be seen . Income loss and economic hardship can lead to feelings of economic stress and consequent marital conflict [21, 22]. Quarantine can lead to decreased freedom and privacy, and consequently higher stress. It may also increase existing controlling behaviors by perpetrators as they struggle to regain a sense of control. Exposure to perpetrators is increased, and the possibilities of victims to temporarily escape abusive partners are reduced . In the current COVID-19 crisis, there have been reports from all over the world about a significant increase in domestic violence . UN secretary general António Guterres pointed out a “horrifying global surge in domestic violence” . Exposure to domestic violence again significantly affects mental health of children [26, 27] and has the potential to create long-term consequences .
Moreover, a notable increase in physical, emotional and sexualized violence against children during recession has been reported. For example, Huang and colleagues were able to prove a doubling of the incidence of abusive head trauma, a particularly severe form of child abuse associated with a high mortality rate, during the “Great Recession” 2007–2010 . In the literature, an increase of all forms of child maltreatment has been proven during a recession in a wide variety of cultures . Based on these data, for the COVID-19 pandemic, a worldwide increase in the risks for children and adolescents is a plausible assumption. The current reduced societal supervision and lack of access to child protection services is an additional burden.
Taken together, despite a lack of literature specifically addressing the impact of recession on children, existing data point towards threats to mental health of children and adolescents. This is confirmed by one study that directly assessed adolescent mental health during the financial crisis in Greece. The researchers found an increase in mental health problems during the recession . Notably, this study also demonstrates that mental health was impaired disproportionately in the most vulnerable socio-economic groups—adolescents whose families faced more severe economic pressure.
Besides economic pressure, COVID-19 pandemic-related quarantine in several countries could significantly affect mental health. In a recent review on the psychological impact of quarantine, Samantha Brooks and colleagues pointed out that post-traumatic stress symptoms (PTSS) occur in 28 to 34% and fear in 20% of subjects in quarantine . Additional quarantine-related mental health problems include depression, low mood, irritability, insomnia, anger and emotional exhaustion . Horesh et al. argue that the COVID-19 crisis involves numerous characteristics seen in mass traumatic events so an increase in PTSS during and after the pandemic can be expected .
The scarcely available data point towards a detrimental effect of disease-containment measures such as quarantine and isolation on the mental health of children. In a study conducted after the H1N1 and SARS epidemics in Central and North America, criteria for PTSD based on parental reporting were met by 30% of the children who had been isolated or quarantined .
Another quarantine-associated threat is an increased risk of online sexual exploitation. Since the beginning of the pandemic, children and adolescents have spent more time online, which may increase the risk of contact with online predators. Due to limited social encounter, children’s outreach to new contacts and groups online has increased. As more adults have been isolated at home, there may also be an extended demand for pornography . Europol has already reported an increase in child pornography since the beginning of the pandemic .
The question remains, whether infection with COVID-19 can directly lead to onset or aggravation of mental disorders. Seropositivity to influenza A, B and Coronaviruses has been associated with a history of mood disorders . In addition, onset of psychotic disorders has been reported to be associated with different Coronavirus strains .
In summary, phases one and two of the current COVID-19 pandemic represent a dangerous accumulation of risk factors for mental health problems in children and adolescents of enormous proportions: re-organization of family life, massive stress, fear of death of relatives, especially with relation to grandparents and great-grandparents, economic crisis with simultaneous loss of almost all support systems and opportunities for evasion in everyday life, limited access to health services as well as a lack of social stabilization and control from peer groups, teachers at school, and sport activities.
Can there be beneficial consequences for mental health from the current crisis?
Together with multiple threats to mental health, the current pandemic could also provide opportunities. When families successfully complete the initial transition phase, the absence of private and business appointments, guests and business trips can bring rest and relaxation into family life. Several external stressors disappear. Mastering the challenges of the COVID-19 crisis together may strengthen the sense of community and cohesion among family members. More time with caregivers can go along with increased social support, which strengthens resilience . In addition, children troubled by school due to bullying or other stressors, can experience the situation of home-schooling as relieving, as a main stressor in their everyday life ceases to exist.
Moreover, mastering current challenges could contribute to personal growth and development. Personal growth is an experience of psychological development as compared with a previous level of functioning or previous attitudes towards life. Thus, successful management of stress and trauma can lead to personal growth, which in turn reinforces the sense of competence and becomes a protective factor for coping with future stressors .
However, environmental factors such as socio-demographics, individual social networks and social support affect the outcome of a crisis [41, 42]. Therefore, the opportunity for personal growth may be unequal (see also “Focus on high risk children”). Nevertheless, personal characteristics determine stress-related growth as well. These factors include intrinsic religiousness and positive affectivity. Intrinsic religiousness is suggested to help to find meaning in crisis, the relevance of positive affectivity shows the importance of positive mood and attitude for stress-related growth .
The long way back to normality after the pandemic (phase three)
One major challenge after the pandemic will be to deal with its sequelae. One main consequence will be the economic recession and its implications for mental health of children and their families, as discussed above. During the acute phase of the pandemic, stressors such as social distancing, re-organization of family life, school and businesses, fear of COVID-19 infections, and possibly loss of family members/friends are initially in the forefront. Economic problems may be recognized mainly after the acute phase of the pandemic, although their starting point was in an earlier phase. Some parents might have lost their jobs or businesses, while others might have to deal with an accumulated workload or face major re-organization at work. For children and adolescents, the pressure from school to catch-up for time lost during the acute phase of the pandemic may increase. However, there is evidence that rate and direction of change in macroeconomic conditions rather than actual conditions affect harsh parenting . This suggests that the expectation of a negative economic development is a stronger determinant of negative parental behavior than actual recession, which could point towards the conclusion that harsh parenting and violence will have its climax during the acute phase of the pandemic.
Due to interruption of regular medical services, resources in the health care system may not be enough to overcome previous lack of treatment and supervision. Moreover, not only the accumulation of inadequately treated cases, but furthermore the enhanced need for mental health services might be a problem. The increase of mental health problems in children and their families due to recession and quarantine is discussed above and can be expected to further increase in phase three due to emerging recession. Literature suggests that mental health symptoms will outlast the acute phase of the pandemic. In health-care workers, the risk for alcohol abuse or dependency symptoms was still increased 3 years after quarantine . A quarter of quarantined subjects avoided crowded enclosed places and one-fifth avoided public spaces .
Additionally, the increased risk of child maltreatment and household dysfunction may not diminish immediately after the pandemic as several triggers such as economic pressure and mental health problems of parents will last for some time. Moreover, sequelae of pandemic-associated increase of maltreatment of children and adolescents may last for a lifetime. Adverse childhood experiences are known to affect the life of survivors across their life span. Long-term effects include increased risk for numerous mental and physical disorders , reduced life quality , developmental and cognitive impairments [48, 49], social problems  and a reduction of up to 20 years in life expectancy .
Focus on high risk children
The consequences of the pandemic can hit every child. However, there are several indicators that children who are already disadvantaged are at highest risk. First, financial losses will cause increased economic pressure to low-income families due to lack of savings. Second, there may be increased disparities between families with high and low socio-economic status, for example due to differences in parental support for home schooling and leisure activities during the pandemic. Specific modalities such as telemedicine and telepsychiatry may be less accessible for children of low-income families who may not have the resources to use telepsychiatry or to use it in a safe and confidential environment.
Another highly vulnerable group is that of children and adolescents with chronic disorders, for whom important support and therapies may have been reduced or cancelled. For children with intellectual disability, it can be hard to understand the situation and the necessity for the restrictions, with consequent increase in anxiety and agitation. Besides, children with disabilities are at higher risk for child maltreatment . During the pandemic, due to lack of social control and impaired ability to communicate, this risk can increase.
Children and adolescents having experienced adverse events before the pandemic occurred are especially vulnerable for consequences of the COVID-19 crisis. The experience of adverse childhood experiences (ACEs) is associated with higher risk for mental health problems. Maltreatment has been found to be associated with consequent heightened neural response to signals of threat . Moreover, while emotional reactivity is increased, emotion regulation is decreased . This suggests that children and adolescents who have experienced adversity before the pandemic are at higher risk to develop anxiety and adopt dysfunctional strategies to manage the COVID-19-associated challenges.
Another important high-risk group is that of children and adolescents with already existing mental health problems. Most mental disorders require regular psychotherapy and psychiatric treatment. Therefore, lack of access to health services can be particularly detrimental. Severity and outcome of mental disorders could worsen because of delay in prompt diagnosis and treatment. This would be especially problematic for conditions such as early onset schizophrenia, in which early treatment is an important prognostic factor. However, there are more pandemic-associated risks for this group. Taking care of children with mental health problems, in particular externalizing disorders, can be challenging —thus adding to the already increased distress of parents during the pandemic.
With increasing levels of psychopathology, capacity for emotion regulation and adaptive coping is reduced, while maladaptive coping increases , a pattern also observed in children and adolescents with a history of child maltreatment . Likewise, children with previously existing psychopathology are at greater risk to show severe worry about political news . Together, this suggests that current COVID-19 crisis-associated stress is particularly harmful for children and adolescents with mental disorders or a history of child maltreatment. On the other hand, stress exposure can enhance already existing psychopathology , which can lead to more severe courses of mental disorders—meeting reduced treatment resources. An impact of recession on self-harm has been shown in different studies, especially after the world economic crisis 2008 . As self-harm is predominantly found among adolescents , an upsurge of self-injurious and suicidal behavior in youth can be hypothesized as a consequence of the COVID-19 pandemic. This issue should receive urgent attention. Thus, it is likely that the COVID-19 pandemic will lead to an exacerbation of existing mental health disorders as well as contribute to the onset of new stress-related disorders in many, especially children and adolescents with pre-existing vulnerabilities—aggravating pre-existing disadvantages.
Unaccompanied and accompanied refugee minors are a high-risk group for all the aforementioned vulnerabilities—low socioeconomic status, experience of ACEs and mental health problems . Additionally, as some early cases of COVID-19 have been reported in refugee institutions, shelters and camps, the consequent panic and fear of infection can increase the risk of stigmatization of refugees. As many countries are hosting a large number of refugees, and there is a lack of medical and psychiatric specialist care for them, COVID-19-associated mental health risk may disproportionately hit these children and adolescents already disadvantaged and marginalized [63, 64].